AMA Clinical Examples in Radiology - 2017 Issue 4 (Fall)
Endovenous Ablation of Incompetent Vein
CLINICAL EXAMPLE 2 Endovenous Ablation of Incompetent Vein CLINICAL HISTORY A 78-year-old female presents with chronic venous insufficiency that involves the left great saphenous vein (GSV). TECHNIQUE Written informed consent was obtained after a discussion of the risks, benefits, and alternatives to the procedure. A preprocedure assessment was documented in the medical record. A time-out was performed immediately prior to the procedure. 99152 99153 Conscious sedation was used for the procedure under the attending physician's direction, and a trained nurse specialist performed continuous monitoring for 35 minutes. Midazolam 2 mg intravenous (IV) and fentanyl 100 μg IV were...
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Article Overview
This article explains how a venous ablation case is coded in the context of CPT and ICD-10-CM guidance, including how the procedure was reported before and after the 2018 CPT update. It is relevant to coders and billers working with vascular procedures, moderate sedation, ultrasound guidance, and diagnosis coding for chronic venous insufficiency. The article also covers the introduction and revision of several CPT codes tied to incompetent vein treatment and related reporting conventions.
Why This Topic Matters
It helps readers understand how this type of vascular procedure aligns with evolving CPT guidance and diagnosis coding rules, which affects claim accuracy and code selection.
Article Sections
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Clinical Example 2
Introduces the case context and the venous condition being addressed in the procedure.
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Clinical History
Summarizes the patient background relevant to the intervention.
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Technique
Describes the procedural workflow, imaging support, sedation, and device-based treatment approach.
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Impression
States the overall procedural outcome of the intervention.
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How to Code
Lists the reporting approach for the case and identifies the code sets and diagnosis category discussed.
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Discussion
Explains the coding context for the case, including CPT and ICD-10-CM guidance and the broader 2018 code changes.
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New Codes for CPT 2018
Summarizes the newly added and revised CPT content related to incompetent vein treatment.
What You Will Learn
- How a venous ablation case is framed for coding review
- Which code sets are discussed in relation to this procedure
- How the article addresses CPT updates over time
- What general topics are covered for sedation, imaging guidance, and diagnosis reporting
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Clinical documentation specialists
- Vascular and interventional radiology coding staff
Codes Discussed
Code Ranges Discussed
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